When it comes to New York City, there are two kinds of
people—those who can live there and those who cannot. To be a true
New Yorker, you have to thrive on the hustle and bustle, the
never-ending cycle of action. There is never a dull day in NYC, and
the people who make it their home would not have it any other way.
That is how Dr. Nirav Shah feels about being a New Yorker. It is
also how he feels about being an internist.

Dr. Nirav Shah and his wife, Nidhi.

“I enjoy being in the middle of the action, dealing with the
most important issues facing medicine today,” said Shah. “Right
now, internal medicine is the best place—the most exciting place—to
be in medicine, because we are on the threshold of significant
change and we are already seeing it happen.”

A Desire for More

A conversation with Shah gives you the sense that he is exactly
where he wants to be in life. Though clearly motivated and hard
working, his demeanor lacks the hurriedness or impatience you might
expect to find in someone so driven. His speaking voice is steady
and pleasant, yet confident and authoritative. He also has a sense
of humor. In other words, he seems like just the kind of doctor you
would want to have.

Shah began his medical career at Harvard College and the Yale
School of Medicine, where he graduated with Honors with a
concentration in the Epidemiology of Chronic Diseases. He completed
residency training in internal medicine at Yale-New Haven Hospital
and followed with a fellowship in health services research at UCLA
in the Robert Wood Johnson Clinical Scholars Program. He is
currently practicing at Manhattan’s Bellevue Hospital and is also
completing his PhD in Epidemiology from UCLA. He has learned many
lessons along the way. While he might be different today than he
was as a fresh-faced medical student, one thing has always been a
constant, which is his love of being an internist.

“I made the decision to pursue internal medicine in the
beginning of medical school,” he said. “Right away I saw all of the
interesting questions I would face every day and I was drawn in. I
recognized that being an internist would allow me to research
across a broad realm and then apply my research to the practice.
One week I would be asking research questions about medication
adherence in asthma and the next week I would be treating an
asthmatic patient. I liked that—it appealed to me.”

Like many physicians practicing internal medicine, Shah craves
stimulation and diversity, which is another reason he cites for his
choice. “My brother, who is an epileptologist in White Plains, New
York spends most of his day looking at electroencephalograms. For
him it is great and he loves it, but it would drive me crazy,” he
said.

“Working in internal medicine gives you the most options and
frankly, the most interesting options. You have much more
flexibility because your skills are transferable. It provides you
with an enviable quality of life, more exposure to a wide range of
diseases and disorders, and camaraderie with a broader range of
people.”

On the Docket

As you might expect of any young and ambitious physician, Shah
has something to say about the direction of internal medicine and
how he plans to be a part of it. The most pressing issues right now
according to Dr. Shah are determining what constitutes appropriate
care and finding the most resourceful, or as he puts it, “creative”
ways to treat patients according to their needs, preferences and
abilities. “We have always had a focus on inpatient, acute care and
most of our attention and resources are directed toward a patient’s
hospitalization,” he said. “Now we are becoming more focused on
ambulatory settings, and as a result the acute care model no longer
works.

“We are moving toward an outpatient model where chronic diseases
are determining how to best organize the delivery of care,” he
continued. “Disease progression and disability are preventable in
patients who suffer from chronic conditions. Efforts to prevent
progression fail in part because patients are not adequately
guided, educated or motivated to manage their own care and risk
factors. We are really transforming how we think of the
doctor-patient relationship to include things like patient-centered
care, electronic health records, and utilizing other health care
team members such as a specialized nurse practitioner.”

Another integral part of this school of thought, Shah explained,
is the role of community and family. “The new models of health care
encourage interaction between the community and the health system,”
he said. “The idea is for communities to work interactively with
the health system. Individuals need to promote health care
awareness while encouraging and assisting patients in taking charge
of their own care.”

Real Patients, Real Challenges

“During my residency, I had a patient named Mrs. Calderon who
was elderly and did not speak any English, so she would bring her
daughter with her to translate. What I learned from her goes beyond
the textbook—medical adherence and the importance of family
dynamics and how they can affect a patient’s well being. The
medical adherence lesson I learned the hard way, when she ended up
taking twice the dose of a medicine I had prescribed for her by
starting on a refill early. After that, I had a new appreciation
for how critical a patient’s understanding is and how you can not
take it for granted.

“The other thing I noticed while I was treating her was how
happy and healthy she was in general, despite her overall economic
and living situation, which was poor. She described her quality of
life as good because she had a strong network of close family and
friends who kept her in good spirits. She never appeared or acted
sick. This is a great example of why the new models of care
involving community and family are so effective.

“I have a similar experience with another patient, Mrs.
Gonzoles,” he continued. “Although she understands everything I
say, whether or not she follows my direction is another story. She
is Haitian and lives in Haiti six months out of the year, during
which she lives a very different lifestyle than the one she lives
in New York. She has many chronic conditions, poor social support
and low health literacy. I see her for thirty minutes three times a
year and just when I think I have her on track with everything she
goes to Haiti for six months. When I say that she has poor health
literacy I mean she does not understand the consequences of her
actions and lifestyle choices.

“I counteract this by getting the whole team on board while
treating her—a diabetes education specialist, a nutritionist and a
social worker. We have a team-based approach at Bellevue and it
works,” he said. “I have a great support staff and all the
resources I need.”

One area he thinks could stand improvement is our understanding
of health literacy, which he said he deals with on a daily basis.
“Mrs. Calderon and Mrs. Gonzoles are exactly the reason why there
needs to be more attention directed toward health literacy,” he
points out. “Poor health literacy means a poor understanding of
what promotes good health and what encourages disease. We need to
direct messages to patients through different media that actually
reach them, like radio and Spanish television.”

More than Dollar Signs

These days, the Buffalo, New York native divides his time
between practicing internal medicine at Bellevue, teaching at the
New York University School of Medicine and doing research at the
Geisinger Health System, where he is an investigator in health
services and outcomes research.

On the issue of an impending primary care crisis, he believes
internists should be in the driver’s seat. “The big question is
whether we are going to shape the debate ourselves or if we are
going to let others decide for us,” he said.

For right now, Shah’s plate is full enough. His wife, Nidhi,
recently gave birth to the couple’s first son, Vir, in September.
Reshaping internal medicine may have to wait for another day, but
Shah is not complaining. “I love the fact that when I come to work
at Bellevue I may hear up to twelve different languages spoken in
one day,” he said. “Internal medicine is so rewarding because of
the relationships you have, not only with patients but with other
doctors. You really get much more exposure to people as an
internist. I lead a good life. While compensation may be an issue
for many, I think it is truly shortsighted to look at medicine, or
any profession, strictly in financial terms. Being an internist
cannot be quantified in terms of a paycheck.”